Patient-Centered Outcomes

Patient Outcome and Resuscitation Team Members Attending Advanced Life Support Courses

Last Full Review: ILCOR 2022
Last Update: 2024

Advanced life support (ALS) courses are offered internationally for healthcare professionals caring for patients of all ages needing resuscitation and life support following a medical or trauma event. A team approach to resuscitation is commonly used in the in-hospital setting. A previous systematic review by the International Liaison Committee on Resuscitation (ILCOR) led to a recommendation for accredited adult ALS training for healthcare providers. Is there evidence to support the same recommendation for healthcare provider training in pediatric advanced life support (PALS) courses, neonatal life support and/or other ALS courses?

 

Evidence Summary

A 2022 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Wyckoff et al. 2022; Lockey et al. 2022) focused on the prior participation of one or more members of the resuscitation team in an accredited ALS course on clinical outcomes of patients of any age requiring resuscitation from an in-hospital cardiac arrest. Studies were identified for adult ALS, neonatal resuscitation training courses and the Helping Babies Breathe course.

For adult ALS courses, an evidence update of the previous systematic review (Lockey et al. 2018, 48) identified a single retrospective descriptive study (Pareek et al. 2018, 381) that supported conclusions from the previous 2020 CoSTR (Greif et al. 2020, S222).

For neonatal resuscitation training, a systematic review (Patel et al. 2017, e000183) of neonatal resuscitation training approaches was identified and used for data extraction and analysis of hospital-based studies. Included studies for this review were pre- and post-intervention studies from low- to middle-resource settings and changes were significant in all outcomes (fresh stillbirths, neonatal mortality at 1-day, 7-day, 28-day and perinatal mortality) except 28-day neonatal mortality. The authors reported statistical and clinical heterogeneity in all outcomes except for all still births but showed a consistent treatment effect with improved outcomes with neonatal resuscitation training. A systematic review (Versantvoort et al. 2018) of the Helping Babies Breathe course was identified and evidence was incorporated into the ILCOR review. This review identified moderate certainty evidence for a decrease in intrapartum-related stillbirth and 1-day neonatal mortality after implementing the Helping Babies Breathe course (Wyckoff et al. 2022; Lockey et al. 2022).

The ILCOR treatment recommendations stemming from the CoSTR include strong recommendations for the provision of accredited ALS training for healthcare providers who provide ALS care for adults and for the provision of accredited courses in neonatal resuscitation training and Helping Babies Breathe for healthcare providers who provide ALS care for newborns and babies (Wyckoff et al. 2022; Lockey et al. 2022).

Insights and Implications

The evidence identified was considered very low certainty but showed a consistent treatment effect with the potential for saving many lives. The review did not identify evidence related to participation in PALS courses or comment on this, and the population of interest was restricted to patients requiring resuscitation from in-hospital cardiac arrest, although resuscitation of out-of-hospital cardiac arrest by emergency medical services responders typically involves teams with training in ALS.

Prearrest Prediction of Survival Following In-Hospital Cardiac Arrest

Last Full Review: ILCOR 2022

The ability to use a clinical decision tool to predict which patients may survive to hospital discharge following in-hospital cardiac arrest could help healthcare professionals understand which patients will benefit from cardiopulmonary resuscitation (CPR) and which patients will not. A clinical decision tool could guide discussions between caregivers, patients, and their families and could guide decision-making for starting or abstaining from CPR (i.e., do-not-attempt-CPR). Many different scoring systems have been designed to predict survival or nonsurvival in in-hospital cardiac arrest. Is there evidence that any prediction rule is more accurate than others?

 

Evidence Summary

A 2022 International Liaison Committee on Resuscitation systematic review (Lauridsen et al. 2022a, 141) and Consensus on Science with Treatment Recommendations (Lauridsen et al. 2022b; Wyckoff et al. 2022) focused on the use of prearrest clinical prediction rules for survival following in-hospital cardiac arrest of adults and children. Included studies investigated 13 different prearrest prediction rules for survival after International Liaison Committee on Resuscitation Meta-analyses were not performed as all included studies were based on retrospective cohort studies and judged at very high risk of bias. Several studies investigated a prearrest morbidity score, the prognosis after resuscitation score (which aims to predict survival to hospital discharge) and the Good Outcome Following Attempted Resuscitation (GO-FAR) score (which aims to predict survival with a Cerebral Performance Category [CPC] score of 1). Other smaller studies reported prediction of survival to hospital discharge with various rules. The review concluded that none of the scores were able to reliably predict survival to hospital discharge or to 30 days and favorable neurological outcome on the basis of patient factors before an n-hospital cardiac arrest, and none were able to reliably predict no chance of survival or chance of survival or favorable neurological outcome (Lauridsen et al. 2022a, 141; Wyckoff et al. 2022).

The International Liaison Committee on Resuscitation recommends against using any currently available prearrest prediction rule as a sole reason to not resuscitate an adult with in-hospital cardiac arrest and is unable to make a recommendation about using prearrest prediction rules to facilitate do-not-attempt-CPR discussions with adult patients or pediatric patients or their surrogate decision maker. No studies with pediatric patients were identified (Lauridsen et al. 2022b; Wyckoff et al. 2022).

Insights and Implications

No prospective studies were identified in the systematic review on clinical implementation of a prearrest prediction model, and thus it remains unknown whether use of any of these prediction rules would impact outcomes, such as initiating do-not-attempt-CPR discussions and orders, patient or family perspectives, survival and CPC scores.

Family Presence in Adult Resuscitation

Last Full Review: ILCOR 2022

Previous International Liaison Committee on Resuscitation (ILCOR) reviews have considered family presence during pediatric resuscitation (Dainty et al. 2021, 20; Wyckoff et al. 2022, e645). Advocates for family presence during resuscitation describe improved coping and grieving for families and reduced litigation, while opponents of family presence cite the impact on team performance, personal stress on healthcare providers, and the potential for mental health and post-traumatic stress disorder (PTSD)-related symptoms in the relatives (Afzali Rubin et al. 2023, Cd013619). What evidence supports family presence during resuscitation of adults?

 

Evidence Summary

A 2022 ILCOR systematic review and Consensus on Science with Treatment Recommendations (CoSTR) (Considine et al. 2022, 11; Eastwood et al. 2022; Berg et al. 2023), sought evidence for family presence during resuscitation (defined as a relative or significant other who is within sight of resuscitation of an adult), with patient-centered, family-/significant-other-centered and healthcare-provider-centered outcomes of interest. A total of 31 studies, including two randomized controlled trials, provided limited evidence of very low certainty due to potential confounding and heterogeneity. Meta-analysis was not possible. Study settings included in-hospital resuscitation in the emergency department, intensive care unit and other critical care areas.

For studies reporting patient-centered outcomes, four studies compared family presence with no family presence (Considine et al. 2022, 11; Eastwood et al. 2022; Berg et al. 2023). Three studies reported no significant difference in survival based on family presence, and one reported a higher rate of return of spontaneous circulation and survival to discharge when family members were not present during resuscitation. Fifteen studies reported family-centered outcomes, such as anxiety and PTSD. Although higher rates of depression or PTSD were reported in some studies, evidence was lacking to show an association between the mental health condition and having witnessed a family member’s resuscitation.

Studies reporting on healthcare professional outcomes noted varying findings. The ILCOR CoSTR (Eastwood et al. 2022; Berg et al. 2023) reported that healthcare providers were, in general, supportive of family presence during resuscitation and felt their function was not impaired by family presence, although some apprehension toward family presence was noted across studies. Healthcare professionals reported that family support personnel, training, and organizational guidelines or protocols were important for facilitating family presence during resuscitation.

A weak recommendation by ILCOR suggests that family members be provided with the option to be present during in-hospital and out-of-hospital adult resuscitation from cardiac arrest, with the acknowledgment that providers are often not able to control this in out-of-hospital settings. Good practice statements were made advocating for: 1) the development of policies or protocols about family presence during resuscitation to guide and support healthcare provider decision-making, and 2) healthcare provider education about family presence during adult cardiac arrest resuscitation and management of stressful situations (Eastwood et al. 2022; Berg et al. 2023).

Insights and Implications

The Red Cross guidelines are informed by the ILCOR systematic review. How family presence during an adult resuscitation is viewed varies across individuals and healthcare professionals. No evidence of harm to family members was found because of their presence during resuscitation. Having an organizational policy, guidelines, training for healthcare professionals and support personnel to facilitate the process may be of benefit for family members and healthcare professionals alike but requires additional resources.